Loss of blood often requires replacement of both the volume of fluid that is lost and the oxygen carrying capacity of that fluid. This is typically accomplished by transfusing red blood cells, either as packed RBC's or as units of whole blood. However, it is not always possible, practical or desirable to transfuse a patient with donated blood. Human blood transfusions are associated with many risks and limitations, such as:
1) Infectious disease transmission (i.e., human immunodeficiency virus (HIV), non-A and non-B hepatitis, hepatitis B, Yersinia enterocolitica, cytomegalovirus, human T-cell leukemia virus 1) PA1 2) Immunologic reaction (i.e., hemolytic transfusion reaction, immunosuppresion, graft versus host reaction) PA1 3) Typing and cross-matching required prior to administration PA1 4) Limited availability PA1 5) Limited stability (shelf life of 42 days or less; cannot be frozen) PA1 Leu-B10.fwdarw.Phe PA1 Val-E11.fwdarw.Phe PA1 both His-E7.fwdarw.Gln and Val-E11.fwdarw.Phe PA1 both His-E7.fwdarw.Gln and Leu-B10.fwdarw.Phe PA1 His-E7.fwdarw.Gln, Leu-B10.fwdarw.Phe and Val-E11.fwdarw.Phe PA1 His-E7.fwdarw.Phe, Leu-B10.fwdarw.Phe and Val-E11.fwdarw.Phe. PA1 Leu-B10.fwdarw.Trp PA1 Leu-B10.fwdarw.Phe PA1 Leu-B10.fwdarw.Val PA1 Leu-B10.fwdarw.Ile PA1 Leu-B10.fwdarw.Ala PA1 His-E7.fwdarw.Leu PA1 His-E7.fwdarw.Trp PA1 Val-E11.fwdarw.Phe PA1 Val-E11.fwdarw.Trp
When human blood is not available or the risk of transfusion is too great, volume can be replaced utilizing plasma expanders such as colloid and crystalloid solutions but to date, none of the volume replacement therapies currently approved for human use can transport oxygen. In situations where replacement of lost blood is necessary and blood is not available for transfusion, a red blood cell substitute that can transport oxygen, such as a hemoglobin solution, is desirable. Administration of a hemoglobin solution can increase and/or maintain plasma volume and decrease blood viscosity in the same manner as conventional plasma expanders, but, in addition, a hemoglobin-based red blood cell substitute should be able to support adequate transport of oxygen from the lungs to peripheral tissues. Moreover, an oxygen-transporting hemoglobin-based solution may be used in most situations where red blood cells are currently utilized. For example, oxygen-transporting hemoglobin-based solution may be used to temporarily augment oxygen delivery during or after pre-donation of autologous blood prior to the return of the autologous blood to the patient.
To address this need, a number of red cell substitutes have been developed (Winslow, R. M.(1992) Hemoglobin-based Red Cell Substitutes, The Johns Hopkins University Press, Baltimore 242 pp). These substitutes include synthetic perfluorocarbon solutions, (Long, D. M. European Patent 0307087), stroma-free hemoglobin solutions, both chemically crosslinked and uncrosslinked, derived from a variety of mammalian red blood cells (Rausch, C. and Feola, M., U.S. Pat. Nos. 5,084,558 and 5,296,465; Sehgal, L. R., U.S. Pat. Nos. 4,826,811 and 5,194,590; Vlahakes, G. J. et al., (1990) J. Thorac. Cardiovas. Surg. 100: 379-388) and hemoglobins expressed in and purified from genetically engineered organisms (for example, non-erythrocyte cells such as bacteria and yeast, Hoffman et al., WO 90/13645; bacteria, Fronticelli, C. et al., U.S. Pat. No. 5,239,061; yeast, De Angelo et al., WO 93/08831 and WO 91/16349; and transgenic mammals, Logan et al., WO 92/22646; Townes, T. M and McCune, S. L., WO 92/11283). These red blood cell substitutes have been designed to replace or augment the volume and the oxygen carrying capability of red blood cells.
The oxygen carrying portion of the red blood cell is the protein hemoglobin. Hemoglobin is a tetrameric protein molecule composed of two identical alpha globin subunits (.alpha..sub.1, .alpha..sub.2), two identical beta globin subunits (.beta..sub.1, .beta..sub.2) and four heme molecules. A heme molecule is incorporated into each of the alpha and beta globins to give alpha and beta subunits. Heme is a large macrocyclic organic molecule containing an iron atom; each heme can combine reversibly with one ligand molecule such as oxygen. In a hemoglobin tetramer, each alpha subunit is associated with a beta subunit to form two stable alpha/beta dimers, which in turn associate to form the tetramer (a homodimer). The subunits are noncovalently associated through Van der Waals forces, hydrogen bonds and salt bridges.
In the unliganded state (deoxygenated or "deoxy") state, the four subunits form a quaternary structure known as "T" (for "tense") state. During ligand binding, the .alpha..sub.1 .beta..sub.1 and .alpha..sub.2 .beta..sub.2 interfaces remain relatively fixed while the .alpha..sub.1 .beta..sub.2 and .alpha..sub.2 .beta..sub.1 interfaces exhibit considerable movement When a ligand is bound to the hemoglobin molecule, the intersubunit distances are increased relative to the deoxygenated distances, and the molecule assumes the "relaxed" or "R" quaternary structure which is the thermodynamically stable form of the molecule when three or more ligands are bound to the heme.
Red blood cell replacement solutions have been administered to animals and humans and have exhibited certain adverse events upon administration. These adverse reactions may include hypertension due to vasoconstriction, renal failure, neurotoxicity, and liver toxicity (Winslow, R. M., ibid., Biro, G. P. et al., (1992) Biomat., Art. Cells & Immob. Biotech. 20: 1013-1020) and in the case of perfluorocarbons, hypertension, activation of the reticulo-endothelial system, and complement activation (Reichelt, H. et al., (1992) in Blood Substitutes and Oxygen Carriers, T. M. Chang (ed.), pg. 769-772; Bentley, P. K. ibid, pp. 778-781). For hemoglobin based oxygen carriers, renal failure and renal toxicity is the result of the formation of hemoglobin .alpha./.beta. dimers. The formation of dimers can be prevented by chemically crosslinking (Sehgal, et al., U.S. Pat. Nos. 4,826,811 and 5,194,590; Walder, J. A. US Reissue Patent RE34271) or genetically linking (Hoffman, et al., WO 90/13645) the hemoglobin dimers so that the tetramer is prevented from dissociating.
However, prevention of dimer formation has not alleviated all of the adverse events associated with hemoglobin administration. Blood pressure changes upon administration of hemoglobin solutions have been attributed to vasoconstriction resulting from the binding of endothelium derived relaxing factor (EDRF) by hemoglobin (Spahn, D. R. et al., (1994) Anesth. Analg. 78: 1000-1021; Biro, G. P., (1992) Biomat., Art. Cells & Immob. Biotech., 20: 1013-1020; Vandegriff, K. D. (1992) Biotechnology and Genetic Engineering Reviews, Volume 10: 404-453 M. P. Tombs, Editor, Intercept Ltd., Andover, England). Endothelium derived relaxing factor has been identified as nitric oxide (NO) (Moncada, S. et al., (1991) Pharmacol. Rev. 43: 109-142 for review); both inducible and constitutive NO are primarily produced in the endothelium of the vasculature and act as local modulators of vascular tone. CO has also been implicated in blood pressure regulation since it can also activate guanylate cyclase (Snyder, S. H. and Bredt, D. S. (1992) Sci. American May, 68-77). Hemoglobin can bind both nitric oxide and carbon monoxide, thus preventing vascular relaxation and potentially leading to the hypertension sometimes observed upon administration of extracellular hemoglobin solutions. In addition to direct binding to deoxyhemoglobin, NO can also oxidize oxyhemoglobin producing peroxynitrite and methemoglobin. This reaction could also lower free concentrations of NO and lead to hypertension.
Some inflammatory responses are also mediated by nitric oxide (Vandegriff, ibid., Moncada, S., et al., ibid.). For example, nitric oxide produced by the endothelium inhibits platelet aggregation and as nitric oxide is bound by cell-free hemoglobin solutions, platelet aggregation may be increased. As platelets aggregate, they release potent vasoconstrictor compounds such as thromboxane A.sub.2 and serotonin (Shuman, M. (1992) in Cecil Textbook of Medicine, J. B. Wyngaarden, L. H. Smith and J. C. Bennett, ed., W. B. Saunders Co, Philadelphia, pages 987-992). These may act synergistically with the reduced nitric oxide levels due to binding by hemoglobin to result in an exaggerated vasoconstriction.
In addition to modulating platelet aggregation, nitric oxide inhibits neutrophil attachment to cell walls. Increased adhesion of neutrophils to cell walls may lead to cell wall damage. Endothelial cell wall damage has been observed upon infusion of some hemoglobin solutions; this kind of damage is consistent with uptake of endogenous nitric oxide by hemoglobin (White, et al., (1986) J. Lab. Clin. Med. 108: 121-131; Vandegriff (1992) ibid). In all these cases, a hemoglobin molecule with reduced reactivity for either binding or oxidizing nitric oxide and with a physiologically acceptable oxygen affinity might ameliorate some of these observed adverse events while still functioning as an effective oxygen carrier.
Conversely, while a moderate production of nitric oxide is required to maintain appropriate vascular tone, excess production of nitric oxide by the endothelium and other nitric oxide producing cells, such as macrophages, may result in pathological states. These disease states include septic shock and nitric oxide mediated hypotension. In these cases, binding of excess nitric oxide or its oxidation by a hemoglobin with a particularly high reactivity for nitric oxide may be useful (Kilbourn, PCT Application Number WO 93/16721).
Another disadvantage of hemoglobin-based blood substitutes has been the tendency of the iron in the heme to undergo oxidation. The oxidation of the iron in the heme from the ferrous (Fe.sup.+2) to the ferric form (Fe.sup.+3) results in the formation of methemoglobin. Methemoglobin is a non-functional form of hemoglobin that cannot bind oxygen, thus its formation in hemoglobin solutions results in reduced capacity to bind gases and may thus require administration of larger amounts of solution to accomplish the same desired benefit or result. In addition, methemoglobin molecules are vulnerable to accelerated degradation due to hemichrome formation, heme loss, precipitation, and reaction with hydrogen peroxide to form toxic radicals and the like (Bunn, H. F. and Forget, B. G. Hemoglobin: Molecular, Genetic and Clinical Aspects, W. B. Saunders Company, Philadelphia, 690 pp, hereby incorporated by reference; Rachmilewitz, E. A. (1974) Sem. Hematol. 11: 441-462).
Myoglobin is a monomeric heme protein found in muscle which binds oxygen reversibly which has often been used as a simple model for the complex chemistry of tetrameric hemoglobin. Myoglobin appears to be an adequate model for ligand binding to the alpha subunits of hemoglobin. In contrast, it is a less satisfactory model for the ligand binding and oxidative behavior of the beta subunit. Moreover, because myoglobin is a non-cooperative molecule, changes in overall ligand affinity and oxidation are not predictable when a mutation in myoglobin is transferred to the equivalent location in the hemoglobin molecule.
Nevertheless, the autooxidation rate and the discrimination between O.sub.2, CO, and NO in both myoglobin and hemoglobin appear to be the result of polar interactions between bound ligands and the histidine found at the E7 position in both proteins. In unliganded myoglobin and the subunits of hemoglobin, a H.sub.2 O molecule is hydrogen bonded to the histidine and must be displaced before a ligand can bind to the iron atom of the heme. The binding of all three ligands requires displacement of this water molecule. In the case of O.sub.2 binding, the inhibition caused by the displacement of the water molecule is overcome by much more favorable hydrogen bonding interactions between His-E7 and the polar Fe.sup..delta. (+)--O--O.sup..delta. (-) complex. No favorable interactions occur between bound CO and the histidine at the E7 position. Thus the affinity of hemoglobin for CO is primarily a function of the intrinsic strength of the covalent bond between CO and the heme iron atom, and as a result, the requirement for H.sub.2 0 displacement results in a net inhibition of CO binding. Without this inhibition, CO would bind approximately 10 fold more tightly to alpha subunits of hemoglobin, and the discrimination against it and for oxygen would be compromised. NO binding shows an intermediate situation; the inhibition due to water displacement is exactly balanced by a weak hydrogen bond with His-E7. As a result, the NO affinity of hemoglobin is similar to that of model heme compounds. Note also that the formation of the iron-oxygen/His E7 complex results in both a net enhancement of oxygen affinity relative to carbon monoxide affinity and a decrease in spontaneous iron oxidation. Thus oxygen affinity and autooxidation are often tightly coupled. In addition, oxidation can occur by an NO mediated mechanism (FIG. 1). NO is a free radical and can react rapidly with reduced iron-oxygen complexes to form peroxynitrite (--OONO) and ferric iron. In hemoglobins and myoglobins, the NO must first diffuse into the heme pocket and take a position in cavity circumscribed by Val(E11), Leu(B10), Phe(CD1), and Leu or Ile(G8) after which reaction with the bound oxygen occurs. Placement of large aromatic residues at these positions should inhibit this oxidative process and prevent NO consumption by oxyhemoglobin.
An effective extracellular hemoglobin blood substitute must bind oxygen cooperatively with moderately low affinity (P.sub.50 .gtoreq.20-30 mm Hg or 30 to 50 .mu.M free O.sub.2 measured at 37.degree. C.): where the P.sub.50 defined as the oxygen partial pressure at half saturation of hemoglobin) and must have large association and dissociation rate constants for oxygen binding to allow efficient uptake in the lungs and delivery in muscle capillaries. The rate and extent of oxygen delivery is proportional to the P.sub.50 of the extracellular hemoglobin or red cells present in muscle capillaries (Vandegriff, K. D., and Olson, J. S. (1984) J. Biol. Chem. 259: 12619-12627.; Lemon, D. et al., (1987) J. Appl. Physiol. 62: 798-806; Nair, P. K. et al., (1989) Microvascular Research 38: 269-285). Lowering oxygen affinity results in more efficient O.sub.2 transport and is limited only by the need to achieve 80-90% saturation in the alveolar capillaries. Unfortunately, almost all attempts to raise P.sub.50 by chemical modification, mutation, and allosteric effectors cause higher rates of autooxidation and subsequent hemin loss and denaturation. Brantley et al. (Brantley, R. E. Jr., et al., (1993) J. Biol. Chem. 268: 6995-7010) have shown that there is strong inverse correlation between oxygen affinity and the rate of autooxidation, k.sub.ox, for 27 different recombinant myoglobins. Similar correlations have been noted both anecdotally and experimentally for tetrameric hemoglobins (Vandegriff, K. D. (1992) Biotechnology and Genetic Engineering Reviews 10: 403-453). This is a major stumbling block for engineering more efficient blood substitutes since stability is compromised by elevated P.sub.50 values.
The dominant mechanism for autooxidation in myoglobin, and quite likely hemoglobin, involves protonation of the Fe(II)--O.sub.2 complex and dismutation into Fe(III) and the neutral perhydroxyl radical HO.sub.2. The bimolecular reaction of molecular O.sub.2 with deoxymyoglobin containing weakly coordinated water only contributes to the observed rate when the unimolecular Fe(II)--O--O--H.sup.(+) dissociation process is slow, and then only when the O.sub.2 concentration approaches the P.sub.50. In native oxymyoglobin, the neutral side chain of His(E7) forms a hydrogen bond with the bound ligand. This interaction increases O.sub.2 affinity and, at the same time, decreases the rate of autooxidation by preventing net protonation of the Fe--O.sub.2 complex since the pK.sub.a for forming the imidazolate anion is .gtoreq.12.
Based on the physical-chemical mechanisms underlying spontaneous and NO induced autooxidation of the heme in the distal pocket and the binding of ligands at the heme group, the inventors have redesigned the active site in the region directly adjacent to the heme iron atom to moderate both the oxidation rate and ligand affinity. The present inventors have been able to develop strategies for selectively altering the specificity of recombinant heme proteins for the three physiologically important gases, O.sub.2, CO, and NO, and for decoupling the rate of oxidation of the iron atom from affinity for gaseous ligands. The present inventors have discovered that if the distal residue histidine at position E7 of either the alpha or the beta globin is replaced with certain other amino acids, the affinity of the resultant hemoglobin mutant for both NO and CO can be increased. Likewise, replacement of leucine at the B10 helical position of the alpha or beta globin can result in a hemoglobin that shows high affinity for NO without a concomittant increase in affinity for CO. In addition, the inventors have also discovered that there are mutations of the distal heme pocket that inhibit dramatically the reactions of NO and CO with hemoglobin. These mutations include replacements of Leu-B10, Val-E11, and His-E7, and various multiple combinations of these mutations, particularly double and triple combinations. Lastly, the present inventors have discovered that to protect against protonation by solvent water and subsequent oxidation of the iron, the spaces adjacent to the bound oxygen can be filled with large aromatic residues. These aromatic groups exclude water by their steric effects and partially stabilize the polar iron-oxygen complex by interactions between the phenyl ring electronic multipole and bound oxygen. The size (the free volume) of the distal pocket can be decreased by introducing these and other mutations, and this decrease in size of the distal pocket also excludes other exogenous oxidizing agents such as NO and H.sub.2 O.sub.2 from direct reaction with bound O.sub.2 (FIG. 1).
Genetic engineering techniques have allowed the expression of heterologous proteins in a number of biological expression systems, such as insect cells, plant cells, transgenic cells, yeast systems and bacterial systems. Because the sequences of alpha and beta globin of hemoglobin are known, and efficient expression criteria have been determined, it is possible that any suitable biological protein expression system can be utilized to produce large quantities of mutant recombinant hemoglobin. Indeed, hemoglobin has been expressed in a number of biological systems, including bacteria (Hoffman et al., WO 90/13645), yeast (De Angelo et al., WO 93/08831 and WO 91/16349; Hoffman et al., WO 90/13645) and transgenic mammals (Logan et al., WO 92/22646; Townes, T. M and McCune, S. L., WO 92/11283).
Mutants of hemoglobin are known and disclosed in PCT publication number WO88/09179, hereby incorporated by reference. Brief reviews of the effects of some distal pocket mutations on ligand binding to myoglobin and hemoglobin have been presented by Perutz (Perutz, M. F. (1989) Trends Biochem. Sci. 14: 42-44); Springer et al. (Springer, B. A., et al. (1994) Chem. Rev. 94: 699-714) and Mathews et al. (Mathews, A. J. et al., (1989) J. Biol. Chem. 264: 16573-16583) and the differences between myoglobin and hemoglobin have been noted in these and other publications. Both the alpha and beta globin subunits have been sequenced (Hoffman and Nagai, U.S. Pat. No. 5,028,588, hereby incorporated by reference) and techniques for the mutation, expression and purification of the mutant recombinant hemoglobins have been described (Looker, D. et al. (1994) Expression of Recombinant Hemoglobin in Escherichia coli In: Methods in Enzymology 231: 364-374, S. O. Colowick, ed.; Academic Press, Inc.; Hoffman et al., WO 93/13645; Milne et al., co-pending U.S. application, Ser. No. 08/339,304, filed Nov. 14, 1994).